Optimizing the Pedicled Latissimus Dorsi Myocutaneous Flap in Breast Reconstruction: Lessons Learned from 110 Consecutive Flaps.

Background: The pedicled latissimus dorsi myocutaneous flap (LDMCF) in autologous breast reconstruction has been superseded by abdominal free tissue transfer. Common complaints of the LDMCF include the asymmetric back scar, need for prosthesis, and high seroma rates. We believe that the LDMCF remains versatile, with distinct advantages over other autologous options: the flap can be harvested unilaterally or bilaterally, not 'burning any bridges' for future reconstruction in unilateral breast reconstruction; the recovery is relatively easy, without complications such as risk of long-term abdominal wall weakness; and the aesthetic results are comparable, if not superior, leading to a more "youthful" result. Methods: We performed a retrospective review over an 8-year period. Results: A total of 106 patients underwent 110 breast reconstructions. Complications included four of 106 patients (3.8%) with seroma, three of 78 (3.8%) with periprosthetic implant infection, and one case of partial flap loss. Conclusions: We learned the following: (1) Direct-to-implant can be performed in most LDMCF patients, avoiding the use of tissue expanders; (2) High BMI patients may not require an implant; (3) Back donor site aesthetics can be improved using a "bra-line-back-lift" approach; (4) Use of liposomal bupivacaine intercostal blocks and modified enhanced recovery after surgery protocol can reduce length-of-stay to overnight; (5) We achieved low seroma rates using topical fibrin glue and closed suction drains; (6) Low and high BMI patients who may not qualify for free tissue transfer are usually still surgical candidates with LDMCF; and (7) Short and long-term recovery are faster than free tissue transfer, with minimal long-term deficit.

Cutaneous metastasectomy: Is there a role in breast cancer? A systematic review and overview of current treatment modalities.

Cutaneous metastases (CM) are neoplastic lesions involving the dermis or subcutaneous tissues, originating from another primary tumor. Breast cancer is commonest primary solid tumor, representing 24%-50% of CM patients. There is no "standard of care" on management. In particular, the role of surgery in the treatment of cutaneous metastases from breast carcinoma (CMBC) remains controversial. This systematic review evaluates the role of cutaneous metastasectomy in breast cancer and provides an overview of existing treatment types.

Short Stay Management of Locally Advanced Breast Cancer Using Immediate Local Thoracoabdominal Advancement Flap and Enhanced Recovery After Surgery Protocol.

BACKGROUND: Patients with locally advanced invasive breast cancer (LABC) are often considered inoperable, because of the anticipated chest wall defect and need for complex reconstruction. We present a series of patients who underwent mastectomy with extensive skin resection and immediate chest wall reconstruction using a local thoracoabdominal advancement flap (TAAF). All patients were managed after surgery with an ERAS (Enhanced Recovery After Surgery) protocol, to decrease length of stay in hospital. We also present 1 patient who subsequently had satisfactory bilateral delayed breast reconstruction with pedicled latissimus dorsi myocutaneous flaps with prepectoral silicone implants. METHODS: This is a single-surgeon, single-institution retrospective chart review of patients with LABC who underwent mastectomy with skin resection and local TAAF from May 2017 to October 2019, with minimum 3-month follow-up. RESULTS: Thirteen patients met inclusion criteria. Twelve of 13 patients presented with stage III or IV invasive breast cancer, with skin involvement. The mean chest wall defect measured 248.7 cm2 (140-336 cm2; SD, 63.2 cm2), and all were successfully reconstructed with immediate local TAAF. There were no intraoperative complications, but 1 patient developed a postop hematoma. The mean hospital stay was 1.3 nights, with 9 patients (69.2%) staying less than 23 hours and 4 patients (30.8%) staying 2 nights. Nine patients (69.2%) underwent adjuvant therapy, beginning on average 32 days (13-55 days; SD, 13.1 days) after surgery. The mean follow-up time was 13.8 months (4.5-31.6 months; SD, 9.2 months). One patient underwent successful delayed bilateral breast reconstruction with pedicled latissimus dorsi myocutaneous flaps and silicone implant placement. CONCLUSIONS: Our study demonstrates that reconstruction with local TAAF is an outpatient procedure that reliably provides durable, immediate chest wall coverage, after mastectomy in patients with LABC. This technique has a short operative time, low blood loss, and low complication rate, allowing timely adjuvant therapy. Using an ERAS postop protocol we were able to reduce mean hospital stay to 1.3 days. Compared with other described techniques of reconstruction, the additional scars and donor site morbidity are minimal, allowing for delayed breast reconstruction. We also present survival outcomes data on these surgically managed patients.

Full thickness penile skin necrosis following HIPEC: Case report and literature review.

Heated intraperitoneal chemotherapy (HIPEC) is commonly performed at the time of tumor resection for metastatic intraabdominal tumors. Post operative complications, such as superficial wound infections or bowel leaks are common. They are largely thought to be secondary to poor wound healing due to chemotherapy-associated neutropenia. Scrotal eschars resulting in full-thickness skin necrosis have rarely been reported as a delayed complication after HIPEC. Here, we present the first case report of penile full-thickness skin necrosis after abdominal cytoreduction with HIPEC combined with ventral hernia repair and mesh placement.

Rectovaginal Fistula Repair 1 Year Later: Lessons Learned.

INTRODUCTION: Rectovaginal (RV) fistulas are notoriously difficult to treat. Various methods for repair exist, and refinements in techniques can lead to "successful" outcomes. Review of the literature demonstrates that outcomes studies are scarce and mostly limited to comments on closure rate. We have experienced "success" in our own series with 100% closure rate, regardless of fistula etiology and comorbidities (radiation, inflammation, etc). However, long-term outcomes, including various complications and quality of life changes, have previously been underreported. METHODS: Critical analysis of various outcomes after fistula repair in 14 patients was performed. Patients were surveyed and interviewed with regard to problems before and after fistula repair to obtain objective data focusing on their experience and outcomes. Conclusions are based on physician assessment and patient surveys 1 year after fistula repair and at least 6 months after ostomy reversal and are discussed within the context of data from the literature. RESULTS: Overall satisfaction rate after repairs was high. All patients would undergo attempt at repair again regardless of complications or functional changes (not present before repair). After repair, sexual dyspareunia affected 5 patients (36%); however, most abstained from sexual activity when their RV fistula became apparent. No patient admitted to dyspareunia before the development of their RV fistula. Anal sphincter and defecation function, as well as stool continence, were judged by surgeons and patients uniformly as adequate. However, 3 patients (21%) complained of intermittent problems with urination. A new/different type of pain affected 2 of 4 patients with Crohn disease. One of these patients subsequently developed a new postsphincteric RV fistula. Another patient noted new intermittent vaginal discharge after ostomy reversal, and magnetic resonance imaging suggested a residual fistula, which was not seen on follow-up sigmoidoscopy and "Blue Dye Test." CONCLUSIONS: We previously reported on algorithms for repair and refinements in techniques for "successful" repair of RV fistulas with zero recurrence rate. Long-term follow-up indicates, however, that although the overall satisfaction rate after surgery is high, true "success," defined as permanent fistula closure, is not necessarily problem free. Long-term morbidity and the management of other unique sequelae and problems are underreported.

Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction: Case Series and Management Guidelines.

INTRODUCTION: Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery. METHODS: This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included. RESULTS: Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days. CONCLUSIONS: Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.

Airway Management in Pierre Robin Sequence: The Vancouver Classification.

BACKGROUND: Pierre Robin sequence (PRS) is a triad of micrognathia, glossoptosis, and respiratory distress. There is no standard clinical classification used in the management of neonatal airway in patients with PRS. The goal of our study was to review the presentation and management of patients with PRS and formulate a clinical grading system and treatment algorithm. METHODS: A 10-year retrospective review of all neonates diagnosed with PRS was performed after obtaining institutional ethics approval. Patients were identified using our cleft lip and palate program database. Inclusion criteria were 2 of the following 3 clinical features-glossoptosis, retrognathia, or airway obstruction. We collected demographic data, clinical information (coexisting airway morbidity, maxillary-mandibular discrepancy, type of intervention used, complications, and outcomes (feeding, length of stay, and airway status) during the first year of life. RESULTS: Sixty-three patients met our inclusion criteria. Of these, 55 (87%) had cleft palate and 17 (27%) were syndromic. Forty-eight (76%) patients were managed by prone positioning. Of the 15 surgically managed patients, the initial procedure was floor of mouth release in 7, mandibular distraction osteogenesis (MDO) in 4, and tongue-lip adhesion in 4. Five patients with coexisting airway morbidity needed a second surgery; 2 had MDO and 3 tracheostomies (one patient was later decannulated). Seven (47%) of the surgically managed patients required a gastrostomy tube. CONCLUSION: At present, there is no consensus on neonatal airway management in infants with PRS. From our review of 63 patients with PRS, we hereby propose a simple 4-point classification system and treatment algorithm, based on clinical features.

HISTORIQUE: Le syndrome de Pierre-Robin (SPR) désigne une triade de micrognathie, de glossoptose et de détresse respiratoire. Aucune classification clinique standard n'est utilisée pour assurer l'ouverture des voies respiratoires chez les nouveau-nés présentant un SPR. La présente étude visait à examiner la présentation et la prise en charge des patients ayant un SPR ainsi qu'à formuler un système de classement clinique et un algorithme de traitement. MÉTHODOLOGIE: Après avoir obtenu l'approbation du comité d'éthique de leur établissement, les chercheurs ont procédé à une analyse rétrospective sur dix ans de tous les nouveau-nés ayant reçu un diagnostic de SPR. Ils ont recensé les patients dans leur base de données de fentes labiales et palatines. Deux des trois caractéristiques cliniques suivantes constituaient les critères d'inclusion : glossoptose, rétrognatie ou obstruction des voies respiratoires. Les chercheurs ont recueilli les données démographiques, l'information clinique (morbidité coexistante des voies respiratoires, malocclusion maxillo-mandibulaire, type d'intervention utilisé, complications et résultats cliniques [alimentation, durée du séjour hospitalier et état des voies respiratoires]) jusqu'à l'âge d'un an. RÉSULTATS: Soixante-trois patients respectaient les critères d'inclusion. De ce nombre, 55 (87 %) avaient une fente palatine et 17 (27 %), un SPR. Quarante-huit patients (76 %) ont été traités par positionnement en décubitus ventral. Des 15 patients opérés, sept ont subi une libération du plancher buccal, quatre, une ostéogenèse par distraction de la mandibule (ODM) et quatre, une adhésion de la langue et de la lèvre. Cinq patients ayant une morbidité concomitante des voies respiratoires ont dû être opérés une deuxième fois. Deux avaient une ODM et trois, une trachéostomie (un a été décannulé par la suite). Sept patients opérés (47 %) ont eu besoin d'une sonde de gastrostomie. CONCLUSION: À l'heure actuelle, il n'y a pas de consensus sur la prise en charge des voies respiratoires chez les nourrissons ayant un SPR. D'après l'analyse de 63 patients ayant ce syndrome, les auteurs proposent un système de classification simple en quatre points et un algorithme de traitement reposant sur les caractéristiques cliniques.

Getting a Valid Survey Response From 662 Plastic Surgeons in the 21st Century.

INTRODUCTION: Web-based surveys save time and money. As electronic questionnaires have increased in popularity, telephone and mailed surveys have declined. With any survey, a response rate of 75% or greater is critical for the validity of any study. We wanted to determine which survey method achieved the highest response among academic plastic surgeons. METHODS: All American Association of Plastic Surgeons members were surveyed regarding authorship issues. They were randomly assigned to receive the questionnaire through 1 of 4 methods: (A) emailed with a link to an online survey; (B) regular mail; (C) regular mail + $1 bill, and (D) regular mail + $5 bill. Two weeks after the initial mailing, the number of responses was collected, and nonresponders were contacted to remind them to participate. The study was closed after 10 weeks. Survey costs were calculated based on the actual cost of sending the initial survey, including stationary, printing, postage (groups B-D), labor, and cost of any financial incentives. Cost of reminders to nonresponders was calculated at $5 per reminder, giving a total survey cost. RESULTS: Of 662 surveys sent, 54 were returned because of incorrect address/email, retirement, or death. Four hundred seventeen of the remaining 608 surveys were returned and analyzed. The response rate was lowest in the online group and highest in those mailed with a monetary incentive. CONCLUSIONS: Despite the convenience and low initial cost of web-based surveys, this generated the lowest response. We obtained statistically significant response rates (79% and 84%) only by using postal mail with monetary incentives and reminders. The inclusion of a $1 bill represented the greatest value and cost-effective survey method, based on cost per response.

Authorship conflicts: a study of awareness of authorship criteria among academic plastic surgeons.

BACKGROUND: Authorship is an important yardstick in academic medicine. The purpose of this study was to assess the prevalence of authorship conflicts among academic plastic surgeons and determine any change in authorship awareness over an 8-year period. METHODS: In 2003, members of the American Association of Plastic Surgeons were surveyed using an anonymous, 15-item, one-page questionnaire. In 2011, members were resurveyed using a similar questionnaire. In both surveys, nonresponders were contacted by telephone at 2 weeks to encourage response. RESULTS: The authors obtained a response rate of 80.4 percent (258 of 321) in 2003 and 81.6 percent (486 of 595) in 2011. In both cohorts, one-third of respondents felt that they had not been appropriately acknowledged as authors at some point during their career. Furthermore, in 2003, 29 percent of respondents admitted to being involved in a dispute with a colleague over authorship issues. This had decreased slightly to 22 percent by 2011. Interestingly, 64 percent of respondents in 2003, compared with only 37 percent of respondents in 2011, stated that they had included someone as an author who had not fulfilled any authorship criteria. In 2003, only 16 percent of respondents were aware of any journal authorship criteria. This had increased to 59 percent by 2011. CONCLUSIONS: The authors found an increase in awareness of authorship criteria among academic plastic surgeons in 2011 compared with those in 2003. In addition, academic plastic surgeons surveyed more recently reported more rigorous justification for including individuals as authors, supporting a trend toward increasing transparency and accountability.

Guide to early surgical management of lip hemangiomas based on our experience of 214 cases.

BACKGROUND: Hemangiomas are the most common vascular lesions in infancy. The majority of hemangiomas occur on the face and cause significant parental distress because of their high visibility. Traditionally, they have been managed by a "watch and wait" approach due to their known propensity to improve significantly over time. This is a particularly difficult approach for hemangiomas of the lips due to their high visibility and their tendency to leave residual deformity even after resolution. METHODS: The authors performed a retrospective chart review of pediatric patients who underwent surgical excision of upper and lower lip hemangiomas at Children's Hospital Los Angeles between 1992 and 2006. RESULTS: The authors identified 214 patients with an average age of 23.6 months at the time of surgery. All patients had improvements in lip appearance, with minimal complications. No transfusions were required, and all but two patients (lip switch flaps for major tissue loss) were managed on an outpatient basis. Overall, complications were minimal, with a high degree of parent satisfaction. CONCLUSION: The authors conclude that many children would benefit from early excision and present guidelines for the early surgical management of lip hemangiomas.

Cysts, pits, and tumors.

SUMMARY: This article discusses common pediatric skin and subcutaneous lesions grouped into three categories: cysts, pits, and tumors. Vascular malformations and hemangiomas are covered elsewhere in this supplement and are not discussed here. In addition, only benign tumors that typically present to the plastic surgeon are mentioned. In a minority of cases, further investigation, in the form of imaging or biopsy, will be required to establish the diagnosis and allow appropriate management. In this article, the authors concentrate on the relevant information required to triage and treat these conditions.

Signaling through Tgf-beta type I receptor Alk5 is required for upper lip fusion.

Cleft lip with or without cleft palate is one of the most common congenital malformations in newborns. While numerous studies on secondary palatogenesis exist, data regarding normal upper lip formation and cleft lip is limited. We previously showed that conditional inactivation of Tgf-beta type I receptor Alk5 in the ectomesenchyme resulted in total facial clefting. While the role of Tgf-beta signaling in palatal fusion is relatively well understood, its role in upper lip fusion remains unknown. In order to investigate a role for Tgf-beta signaling in upper lip formation, we used the Nes-Cre transgenic mouse line to delete the Alk5 gene in developing facial prominences. We show that Alk5/Nes-Cre mutants display incompletely penetrant unilateral or bilateral cleft lip. Increased cell death seen in the medial nasal process and the maxillary process may explain the hypoplastic maxillary process observed in mutants. The resultant reduced contact is insufficient for normal lip fusion leading to cleft lip. These mice also display retarded development of palatal shelves and die at E15. Our findings support a role for Alk5 in normal upper lip formation not previously reported.

Tissue-specific expression of Cre recombinase from the Tgfb3 locus.

Tgfb3, a member of the TGF-beta superfamily, is tightly regulated, both spatially and temporally, during embryogenesis. Previous mouse knockout studies have demonstrated that Tgfb3 is absolutely required for normal palatal fusion and pulmonary development. We have generated a novel tool to ablate genes in Tgfb3-expressing cells by targeting the promoterless Cre-pgk-Neo cassette into exon 1 of the mouse Tgfb3 gene, which generates a functionally null Tgfb3 allele. Using the Rosa26 reporter assay, we demonstrate that Cre-induced recombination was already induced at embryonal day 10 (E10) in the ventricular myocardium, limb buds, and otic vesicles. At E14, robust recombination was detected in the prefusion palatal epithelium. Deletion of the TGF-beta type I receptor Alk5 (Tgfbr1) specifically in Tgfb3 expressing cells using the Tgfb3-Cre driver line lead to a cleft palate phenotype similar to that seen in conventional Tgfb3 null mutants. In addition, Alk5/ Tgfb3-Cre mice displayed hydrocephalus, and severe intracranial bleeding due to germinal matrix hemorrhage.

Palatal fusion - where do the midline cells go? A review on cleft palate, a major human birth defect.

Formation of the palate, the organ that separates the oral cavity from the nasal cavity, is a developmental process characteristic to embryos of higher vertebrates. Failure in this process results in palatal cleft. During the final steps of palatogenesis, two palatal shelves outgrowing from the sides of the embryonic oronasal cavity elevate above the tongue, meet in the midline, and rapidly fuse together. Over the decades, multiple mechanisms have been proposed to explain how the superficial mucous membranes disappear from the contact line, thus allowing for normal midline mesenchymal confluence. A substantial body of experimental evidence exists for cell death, cell migration, epithelial-to-mesenchymal transdifferentiation (EMT), replacement through new tissue intercalation, and other mechanisms. However, the most recent use of gene recombination techniques in cell fate tracking disfavors the EMT concept, and suggests that apoptosis is the major fate of the midline cells during physiological palatal fusion. This article summarizes the benefits and drawbacks of histochemical and molecular tools used to determine the fates of cells within the palatal midline. Mechanisms of normal disintegration of the midline epithelial seam are reviewed together with pathologic processes that prevent this disintegration, thus causing cleft palate.

Transforming growth factor-beta3 affects plasminogen activator inhibitor-1 expression in fetal mice and modulates fibroblast-mediated collagen gel contraction.

For over two decades, the precise role of transforming growth factor-beta (TGF-beta) isoforms in scarless healing of mammalian fetal skin wounds has generated much interest. Although their exact role remains to be established, it has been suggested that high TGF-beta3 activity may correlate with a scarless phenotype. Previously, we showed that plasminogen activator inhibitor-1 (PAI-1), a known TGF-beta downstream molecule and marker of fibrosis, is also developmentally regulated during fetal skin development. In this study, the relationship between TGF-beta3 and PAI-1 was investigated using embryonic day 14.5 TGF-beta3 knockout (ko) mice. The results showed increased PAI-1 expression in the epidermis and dermis of ko mice, using an ex vivo limb-wounding study. Furthermore, increased PAI-1 expression and activity was seen in embryo extracts and conditioned media of ko dermal fibroblasts. When TGF-beta3 knockout fibroblasts were placed into three-dimensional collagen matrices, they were found to have decreased collagen gel contraction, suggesting altered cell-matrix interaction. These findings provide a further avenue for the interactive role of TGF-beta3 and PAI-1 during fetal scarless repair.

Epithelial and ectomesenchymal role of the type I TGF-beta receptor ALK5 during facial morphogenesis and palatal fusion.

Transforming growth factor beta (TGF-beta) proteins play important roles in morphogenesis of many craniofacial tissues; however, detailed biological mechanisms of TGF-beta action, particularly in vivo, are still poorly understood. Here, we deleted the TGF-beta type I receptor gene Alk5 specifically in the embryonic ectodermal and neural crest cell lineages. Failure in signaling via this receptor, either in the epithelium or in the mesenchyme, caused severe craniofacial defects including cleft palate. Moreover, the facial phenotypes of neural crest-specific Alk5 mutants included devastating facial cleft and appeared significantly more severe than the defects seen in corresponding mutants lacking the TGF-beta type II receptor (TGFbetaRII), a prototypical binding partner of ALK5. Our data indicate that ALK5 plays unique, non-redundant cell-autonomous roles during facial development. Remarkable divergence between Tgfbr2 and Alk5 phenotypes, together with our biochemical in vitro data, imply that (1) ALK5 mediates signaling of a diverse set of ligands not limited to the three isoforms of TGF-beta, and (2) ALK5 acts also in conjunction with type II receptors other than TGFbetaRII.

Plasminogen activator/plasmin system: a major player in wound healing?

The role of the plasminogen activator/plasmin system in fibrinolysis has been well established. Indeed, clinicians worldwide have successfully utilized recombinant tissue-type plasminogen activator as first-line treatment of acute myocardial infarction for almost 2 decades. Outside the field of cardiology, there has been increasing excitement regarding the possible contribution of this system in many other important biological processes, including cell adhesion, cell migration, cell-cell signaling, tumor invasion and metastasis, ovulation, and wound healing. In this review, we present evidence in the current literature that the plasminogen activator/plasmin system does have a role in wound healing, looking at both normal and abnormal healing. Furthermore, the invaluable insights provided by numerous transgenic animal experiments are summarized.